What are the differential diagnoses and treatment options for a patient presenting with throat pain and tongue soreness, without fever or difficulty swallowing?

Differential Diagnoses for Throat Pain with Tongue Soreness (No Fever, No Dysphagia)

In a patient with throat pain and tongue soreness without fever or difficulty swallowing, the most likely diagnosis is viral pharyngitis, which requires only symptomatic treatment with ibuprofen or paracetamol—antibiotics should be withheld. 1, 2

Most Likely Etiologies

Viral Pharyngitis (Most Common)

• Viral infections are the predominant cause of acute pharyngitis, including adenovirus, parainfluenza virus, rhinovirus, respiratory syncytial virus, coxsackievirus, ECHO viruses, and herpes simplex virus 1
• The absence of fever strongly suggests a viral rather than bacterial etiology 1
• These infections are self-limiting and do not require antibiotic therapy 1, 3

Non-Streptococcal Causes to Consider

• Epstein-Barr virus (infectious mononucleosis) may present with pharyngitis, though typically accompanied by generalized lymphadenopathy and splenomegaly 1
• Herpes simplex virus can cause pharyngitis with characteristic vesicles 1, 4
• Coxsackievirus (herpangina) presents with vesicles, which may explain tongue discomfort 4
• Candidal infection should be considered, particularly if there are risk factors for immunosuppression 4

Less Common Bacterial Causes

• Groups C and G β-hemolytic streptococci can cause pharyngitis but are less common than Group A streptococci 1
• Arcanobacterium haemolyticum is rare in the United States but may present with pharyngitis and a scarlatiniform rash 1
• Neisseria gonorrhoeae should be considered in sexually active individuals with appropriate risk factors 1, 4

Non-Infectious Considerations

• Tongue abscess is rare but presents with severe tongue pain, swelling, and difficulty swallowing—though your patient denies dysphagia, this makes it less likely 5
• Thyroiditis is an uncommon cause of throat pain 4

Clinical Assessment Algorithm

Step 1: Rule Out Group A Streptococcal Pharyngitis

• Group A streptococcus is the only common form of acute pharyngitis requiring antibiotic treatment 1
• Typical features include: sudden onset sore throat, pain on swallowing, fever, tonsillopharyngeal erythema with/without exudates, tender anterior cervical lymphadenopathy, and scarlatiniform rash 1
• Your patient's lack of fever makes streptococcal pharyngitis unlikely 1
• If clinical suspicion exists, perform rapid antigen detection test (RADT) or throat culture 1, 6
• A negative RADT in adults is sufficient to rule out streptococcal pharyngitis—no confirmatory culture needed 6

Step 2: Identify Red Flags for Serious Conditions

• Look for conjunctivitis (adenovirus), generalized lymphadenopathy/splenomegaly (EBV), vesicles (herpangina or HSV), membrane (diphtheria), cherry-red epiglottis (H. influenzae type b), or atypical pneumonia (M. pneumoniae, C. pneumoniae) 4
• Tongue swelling with fluctuance, high fever, and respiratory distress would suggest tongue abscess requiring urgent surgical drainage 5
• Peritonsillar or retropharyngeal abscess requires surgical intervention 4

Step 3: Consider Sexual History and Immunocompromise

• In sexually active patients, consider gonococcal pharyngitis 1, 4
• Candidal infection in the appropriate clinical context should prompt HIV testing 4

Treatment Approach

Symptomatic Management (First-Line)

• Ibuprofen is the preferred first-line treatment if no contraindications exist, as it appears slightly more effective than paracetamol for pain relief 2, 7
• Paracetamol is an acceptable alternative with equivalent efficacy and safety for short-term use 2, 7
• Both medications are effective for reducing acute sore throat symptoms with strong evidence 2

Adjunctive Therapies

• Consider topical treatments such as local anesthetic sprays or lozenges for additional symptom relief 2
• Flurbiprofen 8.75 mg lozenges provide effective relief for swollen and inflamed throat symptoms 8

What NOT to Use

• Do not use local antibiotics or antiseptics—most sore throats are viral and these lack efficacy data 2
• Corticosteroids should not be routinely used in self-care settings 2, 7
• Zinc gluconate is not recommended due to conflicting efficacy and increased adverse effects 2, 7
• Herbal remedies and acupuncture lack reliable efficacy data 2, 7

Antibiotic Stewardship

• Withhold or discontinue antibiotics for patients with negative strep tests or low clinical suspicion 1, 6
• Treating based on clinical symptoms alone without laboratory confirmation leads to antibiotic overuse 6
• Most throat infections are viral and resolve without antibiotics 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically without testing—this drives antimicrobial resistance and provides no benefit in viral pharyngitis 6, 3
• Do not assume all throat pain requires antibiotics—the vast majority of cases are self-limiting viral infections 1, 3
• Do not overlook serious conditions like peritonsillar abscess, tongue abscess, or epiglottitis that require urgent intervention 4, 5
• Do not ignore sexual history—gonococcal pharyngitis requires specific antibiotic treatment 1, 4

Patient Education and Empowerment

• Educate patients that most sore throats are viral and self-limiting 3
• Provide information on expected clinical course and effective self-management options 3
• Address patient expectations regarding antibiotics using empathetic, non-paternalistic communication 3
• Focus on severity and risk of complications rather than just bacterial vs. viral etiology 3